2 English reference * * * Periodontitis
Overview of adult periodontitis (AP), also known as chronic periodontitis (CAP), is the most common type I periodontitis, accounting for about 95% of periodontitis patients. It is caused by long-term chronic gingivitis spreading to deep periodontal tissue. The older you get, the higher the prevalence rate and the more serious your illness is. More common in adults, the process is slow and can last for ten or decades. The number of dental plaque and tartar is consistent with the severity of periodontal tissue injury. The gums are bloodshot, swollen, soft and prone to bleeding. Attachment loss, periodontal pocket formation, and even pus overflow. Alveolar bone absorption is mainly horizontal absorption, and vertical absorption can occur when occlusal trauma occurs. Chewing weakness, tooth displacement and loosening. Bad breath, retrograde pulpitis and other manifestations. Although there are obvious pathological differences between gingivitis and periodontitis, they are gradually transitional in clinic, so early detection and diagnosis of periodontitis should be paid attention to.
4 Disease Name Adult Periodontitis
5 English name * * * periodontitis
6 adult periodontitis alias chronic periodontitis * * * periodontitis
7 classification stomatology > periodontal disease > periodontitis
8 ICD number K05.5
The prevalence of periodontitis in epidemiology increased significantly after the age of 35, and its severity also increased with age.
10 etiology Periodontal disease is a multifactorial disease, and its etiology is traditionally divided into local factors and systemic factors. Among the local factors, plaque bacteria and their products are the main causes of periodontal disease, and dental calculus, food impaction and poor repair aggravate the retention of plaque. Plaque bacteria is a necessary initial factor leading to periodontal disease, but it is influenced by other local factors and regulated by systemic factors. Systemic factors can change the host's response to local factors, and the host's response is also an important factor. Various factors in multi-factors are interrelated, influence each other, or cooperate and antagonize each other.
1 1 Pathogenesis When the dynamic balance between bacterial invasion and host defense is maintained, the pathogenic effect of a small amount of plaque can be controlled by the host defense function, and the periodontal tissue can still remain healthy. Whether periodontal infection can be established is actually determined by bacteria, host and environment. Some local promoting factors, such as dental calculus, food impaction, trauma, some local anatomical factors, bad habits and bad prostheses, can enhance bacterial invasion, while some systemic promoting factors, such as endocrine disorders, smoking, mental stress, immune deficiency, genetic factors and malnutrition, can reduce the host's defense. When the normal flora loses mutual restraint, or the periodontal microorganisms lose balance with the host, it is transformed into ecological imbalance and periodontal disease occurs. From another point of view, it is difficult and unnecessary to remove all the bacteria of periodontal disease. The prevention and treatment of periodontal disease is to rebuild the microecosystem that is beneficial to periodontal health by weakening the invasion of bacteria or strengthening the defense of the host, which is the ecological regulation therapy involved in periodontal disease prevention and treatment. Page and Komman proposed the interaction of pathogenic factors of periodontitis (Figure 1).
When the number and mutual incompatibility of microorganisms are enhanced, or the body's defense ability is weakened, a large number of periodontal pathogens, such as Porphyromonas gingivalis, Plasmodium intermedium, Actinobacillus, Bacteroides Forsythia, Fusobacterium nucleatum, spirochete, etc., breed in subgingival plaque due to the characteristics of subgingival microecological environment and the nutrition provided by inflammatory products, which aggravate and prolong gingival inflammation, leading to collagen destruction, combined epithelium proliferation to root, tooth pocket formation, etc.
12 The clinical manifestations of adult periodontitis generally invade most teeth in the whole mouth, and a few eloquence occurs in a group of teeth (such as incisors) or individual teeth. The disease can begin in youth, alternating between active and static periods, and the course of the disease lasts for more than ten years or even decades. There are often a lot of tartar and plaque on the surface of teeth. Gingiva presents chronic inflammation in different degrees, with dark red or bright red color, soft texture, disappearing stippling, gingival edema and blunt edges. There is bleeding and pus overflow on the inner wall of the probe bag. There was periodontal pocket and alveolar bone absorption in the early stage, but the teeth were not loose because of the light degree. To determine the severity of periodontal tissue injury caused by late connective tissue attachment loss and alveolar bone absorption;
① Mild: gingival inflammation and bleeding, periodontal pocket ≤4mm, attachment loss12 mm; ; X-ray film showed that alveolar bone absorption was less than 1/3 root length.
② Moderate: dentition: inflammation, bleeding and pus in the gums, periodontal pocket ≤6mm, and attachment loss of 35mm；; X-ray film shows that the horizontal or angular absorption of alveolar bone exceeds 1/3 root length, but does not exceed 1/2 root length. Teeth may be slightly loose, and many teeth may have slight lesions in the root bifurcation area.
③ Severity: obvious gingivitis or periodontal abscess and periodontal pocket >: 6mm, loss of adhesion > 5mmx. X-ray film showed that alveolar bone absorption was greater than 1/2 root length, many teeth had furcation lesions and many teeth were loose. In the late stage of periodontitis, in addition to the four characteristics of periodontal pocket formation, gingival inflammation, alveolar bone absorption and tooth loosening, other accompanying symptoms often appear, such as:
① tooth displacement;
② food impaction;
③ Secondary occlusal trauma;
④ Root surface exposure, temperature sensitivity or root surface gingiva;
⑤ Acute periodontal abscess;
⑥ retrograde pulpitis;
7 bad breath.
In the occurrence and development of adult periodontitis, there are often the following clinical manifestations:
12. 1 Expression of gingivitis As an important part of periodontal tissue, gingiva shows some changes in the early stage of adult periodontitis, mainly inflammation and bleeding of gingiva.
(1) Changes in color, shape and quality of gums: Normal gums are pink with knife-thin edges and close to the neck of teeth; Sticking gum is a bit colorful. Healthy gums are dense, tough and elastic. When suffering from adult periodontitis, the gingival tissue may be inflamed, and the wandering gums and gums may be bright red or dark red. In severe cases, the scope of inflammation can spread to the attached gums, corresponding to the scope of periodontal pockets. At the same time, due to the swelling of tissue during inflammation, the gingival margin becomes thicker, and the gingiva becomes round and dull, which is no longer close to the tooth surface; The surface of gingival tissue is bright, and the stippling disappears due to tissue edema. Due to the infiltration of inflammation and the destruction of collagen fibers, the texture of gingival tissue becomes soft and fragile and loses its elasticity. In the case of chronic inflammation, epithelium can proliferate and thicken, collagen fibers proliferate, and gums can become tough and hypertrophy.
(2) Bleeding tendency of gingival tissue: Healthy gums will not cause bleeding even if they gently brush their teeth or explore the gingival sulcus. Gum bleeding is often the main symptom of adult periodontitis; It usually happens when brushing teeth and biting hard objects, and occasionally there may be spontaneous bleeding.
12.2 The formation of periodontal pocket is a pathological deepening of gingival sulcus, which is one of the most important pathological changes and clinical features of adult periodontitis. Generally speaking, the periodontal pocket consists of soft tissue wall and root wall, and there are a lot of bacteria, food residue, saliva mucin, exfoliated epithelial cells and white blood cells in the pocket. The epithelium of the soft tissue wall of periodontal pocket is often edema and degeneration, which can form ulcers. After probing the periodontal pocket, it can bleed, and a large number of inflammatory cells infiltrate the connective tissue under the epidermis. After the death of white blood cells, pus will overflow from periodontal pocket, which is clinically manifested as pus overflowing from periodontal pocket. The root wall of periodontal pocket is usually covered with plaque and tartar. Due to the effect of plaque and its products, cementum on the root surface can be demineralized and softened. The root wall of periodontal pocket was not smooth during probing.
12.3 attachment lost healthy periodontal tissue, the depth of gingival sulcus was less than 2mm, and the combined epithelium was located at the boundary of enamel cementum, forming epithelial attachment and sealing the bottom of gingival sulcus. In adult periodontitis, the combined epithelium proliferates to the root, and the crown is separated from the tooth surface, forming a periodontal pocket. At this time, the attachment position of epithelium has moved to the root of enamel cementum, that is, attachment loss has occurred. Whether there is attachment loss is the key to distinguish gingivitis from periodontitis. The amount of attachment loss is expressed by subtracting the distance between gingival margin and enamel boundary from the distance between gingival margin and periodontal pocket bottom, plus the distance between gingival margin and periodontal pocket bottom and enamel boundary to gingival margin when gingiva retracts.
12.4 alveolar bone resorption is an important clinical manifestation of adult periodontitis. The absorption of alveolar bone can often be manifested in the following forms:
(1) Horizontal absorption: This is the most common absorption form of alveolar bone. Absorb from the top edge of alveolar ridge to the root level, reduce the height of alveolar bone, and form the supraosseous pocket.
(2) Vertical absorption: refers to the vertical or oblique absorption of alveolar bone, forming angular bone defect between alveolar bone and root surface, and the height of alveolar ridge is not significantly reduced. Vertical bone resorption mostly forms subchondral pocket.
(3) Other forms of alveolar bone absorption: Pit-like absorption is also a common form of alveolar bone absorption, which often occurs in the alveolar septum, and its central part is rapidly destroyed, while the buccal and lingual bones remain, forming pit-like or crater-like defects.
12.5 loose teeth and displaced healthy teeth have certain physiological mobility, but the mobility range is very small; When suffering from adult periodontitis, the mobility of teeth exceeds the physiological range, which is called tooth loosening. This is due to the absorption of alveolar bone and the loss of periodontal supporting tissue during periodontitis. Tooth loosening is also one of the main clinical manifestations of periodontitis. When alveolar bone absorption and periodontal supporting tissue loss reach a certain amount, periodontitis teeth can be displaced from their normal positions under the action of force, which is also a common clinical manifestation of adult periodontitis. Causes of tooth looseness and displacement:
(1) alveolar bone resorption: Periodontitis leads to alveolar bone resorption, which reduces the amount of periodontal supporting tissue. To a certain extent, the teeth become loose and can be displaced under the action of force. Therefore, in the early stage of adult periodontitis, the teeth are not loose, and only when the condition develops to a certain extent will the teeth be loose and displaced.
(2) Bite injury: Excessive bite force can cause alveolar bone absorption, widening periodontal ligament space and loosening and displacement of teeth.
(3) Others: Acute inflammation of periodontal ligament makes periodontal fibers hyperemia and edema, which can lead to tooth loosening and displacement, periodontal surgery trauma, tissue edema and increased tooth looseness.
12.6 during the secondary traumatic periodontitis, the supporting force of periodontal tissue was obviously weakened due to the absorption of alveolar bone and the destruction of periodontal supporting tissue, which could not adapt to the original physiological bite force, resulting in secondary trauma and more serious destruction of periodontal tissue.
12.7 periodontal atrophy refers to the simultaneous destruction and loss of alveolar bone, periodontal fiber and gingival tissue caused by long-term chronic inflammation, which eventually leads to root exposure. Periodontal atrophy is a common clinical manifestation of adult periodontitis. With the aging of adult periodontitis patients and the long-term existence of local factors, the destruction of periodontal tissue is gradually aggravated, and the number of teeth with periodontal atrophy is gradually increasing. Because of periodontal atrophy and root exposure, teeth often have allergic symptoms, and because root cementum is directly exposed to oral environment, root caries is also prone to occur. The atrophy of periodontal tissue in adjacent areas leads to food impaction, which can aggravate the inflammation and destruction of periodontal tissue. Tooth root exposure caused by periodontal atrophy of upper anterior teeth affects aesthetics.
12.8 Periodontal abscess is also a common clinical manifestation of adult periodontitis. Especially in the late stage of periodontitis, deep periodontal pockets appear in the affected teeth. When suppurative inflammation occurs in the periodontal pocket and the drainage is not smooth, periodontal abscess is easy to form.
Periodontal abscess is generally an acute process of acute onset, which forms a hemispherical swelling process at the gum of the affected tooth. Local gingival tissue edema, redness and brightness, obvious pain in the early stage of abscess formation. Affected teeth may feel floating, loose and painful. After the abscess is localized, the pain is relieved and a sense of fluctuation can be felt locally. Sometimes the abscess can rupture on its own, forming a sinus on the gum surface to discharge pus, which becomes a chronic periodontal abscess.
12.9 retrograde pulpitis periodontal disease can cause pulp tissue lesions to some extent. For adult periodontitis teeth, bacteria and toxins in the depth of periodontal pocket can enter the pulp through apical foramen or lateral root canal, causing pulpitis in the corresponding part, which is called retrograde pulpitis. Clinically, teeth suffering from retrograde pulpitis can be characterized by typical acute pulpitis and sometimes chronic pulpitis.
12. 10 Clinical judgment of active periodontitis For a long time, it has been traditionally considered that periodontal disease is a chronic and continuous progressive disease, and the destruction of periodontal tissue is a progressive destruction process. Until the mid-1980s, scholars put forward that the progress of periodontitis is not a chronic, continuous and progressive deterioration, but a periodic feature, that is, the disease appears alternately in a sudden active period and a static period, and the duration of each period is different. The emergence of this sudden active period may be due to the proliferation of pathogenic bacteria, which leads to the rapid destruction of periodontal tissue. When the body's defense function and bacterial invasion reach a state of balance, the disease appears as a static period. This kind of periodontal disease presents a new concept of periodic progress, which has aroused people's attention to the essence, transformation mechanism and clinical judgment of active periodontal disease.
(1) probe bleeding in periodontal pocket: probe bleeding refers to a small amount of blood flowing out of gingival sulcus or periodontal pocket after being gently explored with a blunt probe. The detection of bleeding in periodontal pocket shows that there is inflammation in the epithelium of the inner wall of periodontal pocket or the epithelium of the bottom of periodontal pocket and the connective tissue under the epidermis, which is of great significance to judge the activity of periodontitis. Studies have shown that the relationship between probing bleeding and periodontal tissue destruction is closer than other clinical indicators.
(2) Periodontal pocket overflow or acute periodontal abscess: When suppurative inflammation occurs at the bottom of the periodontal pocket or the inner wall of the pocket, pus can overflow from the mouth of the pocket, which is called periodontal pocket overflow. Once the drainage is not smooth, acute periodontal abscess can occur, leading to tissue destruction. This is also the clinical manifestation of active periodontitis.
(3) Chewing pain and tapping pain: When the teeth of adult periodontitis have chewing pain and tapping pain, it indicates that there is inflammation at the deep bottom of periodontal pocket, and periodontal tissue is in an active period of inflammation and tissue destruction is taking place.
(4) The tooth mobility is obviously increased or retrograde pulpitis appears recently: The tooth mobility of adult periodontitis patients is obviously increased recently, indicating that there is progressive destruction of alveolar bone or edema of periodontal tissue. All these indicate that periodontal tissue is in the active stage of inflammation. Studies have shown that if retrograde pulpitis occurs in teeth with deep periodontal pockets, it also indicates that periodontitis is active.
12. 1 1 Clinical characteristics of adult periodontitis with occlusal trauma; Periodontitis with obvious occlusal trauma is called compound periodontitis. This type of periodontitis often shows some typical clinical features in clinic:
(1) Limited narrow and deep periodontal pocket: The limited narrow and deep periodontal pocket in adult periodontitis teeth suggests that the tooth may have occlusal trauma, which may be the result of the interaction of inflammation and traumatic force.
(2) Isolated furcation lesion of posterior root: If adult periodontitis patients have furcation lesion of single posterior tooth, it is also a sign of occlusal trauma.
(3)X-ray film shows vertical bone absorption: on X-ray film, alveolar bone absorption is vertical, forming subchondral capsule. This is the clinical feature of compound periodontitis. It shows that the periodontal ligament space at the top of alveolar ridge is wedge-shaped, the periodontal ligament on one or both sides of root is widened, the bony plate disappears or does not continue, or it can be thickened locally.
(4) Tooth looseness exceeds alveolar bone absorption: This is also a clinical feature of teeth with compound periodontitis, indicating that alveolar bone around the root is absorbed more.
(5) Asymmetric gingival recession, gingival fissure, gingival marginal process, etc. These changes of gingival tissue are considered to be related to occlusal trauma.
(6) Uneven wear of teeth: Uneven wear such as facet formation indicates occlusal trauma.
(7) cracked teeth, broken roots or severe root resorption: these are also manifestations of compound periodontitis.
(8) Bruxism, the habit of clenching teeth and temporomandibular joint dysfunction are often accompanied by occlusal trauma.
(9) Wedge-shaped defect of tooth neck.
13 adult periodontitis complications: secondary trauma, retrograde pulpitis, asymmetric gingival recession, gingival fissure, gingival marginal process, uneven tooth wear, cracked teeth, broken roots or severe root resorption.
14 x-ray examination.
It is not difficult to diagnose adult periodontitis with 15. According to the clinical characteristics of adult periodontitis mentioned above, a correct diagnosis can be made. However, the difference between early periodontitis and gingivitis is not obvious, and it needs to be diagnosed in time through careful examination to avoid delaying treatment.
Early diagnosis and timely treatment of adult periodontitis are of great significance to prevent the aggravation of the disease and preserve the complete dentition. After the diagnosis of adult periodontitis, the severity and current activity should be determined according to the condition, so as to make a treatment plan and judge the prognosis.
16 the differential diagnosis of early periodontitis should be different from gingivitis, and it should be diagnosed in time through careful examination to avoid delaying treatment. The key difference between early adult periodontitis and gingivitis lies in the loss of periodontal supporting tissue, that is, the loss of attachment and the bone absorption at the crest of alveolar bone (table 1).
17 is effective in the early treatment of adult periodontitis, which can prevent the progress of the disease. Connective tissue and alveolar bone have been repaired to some extent. As long as the patient's serious cooperation and regular maintenance treatment can be obtained, the lesion will not develop again, and the affected teeth can be preserved and function for a long time. The main cause of this disease is plaque, tartar and other local substances, so the treatment should focus on eliminating the local causes, supplemented by surgery, in order to correct the abnormal periodontal tissue morphology caused by the lesions. Because the degree of illness of each tooth in the mouth is inconsistent with the number of causes, it is necessary to make a treatment plan one by one according to the specific situation of each tooth.
17. 1 local treatment (1) dental plaque control: dental plaque is constantly formed on the surface of teeth and cannot be treated by doctors alone. It is necessary to carefully explain the harm of dental plaque to patients, how to find and remove dental plaque, and fully understand the importance of persisting in removing dental plaque. This kind of health education should run through the whole treatment process. Every time a patient visits a doctor, the medical staff should check the degree of plaque control and make records. Try to make the dental surface with plaque only account for less than 20% of all dental surfaces.
(2) Thoroughly remove dental calculus and level the root surface: the removal of supragingival dental calculus and subgingival dental calculus is called supragingival scaling and subgingival scaling respectively. On the basis of subgingival curettage, it is biologically acceptable to further curettage the diseased cementum exposed in the periodontal pocket containing a large amount of endotoxin, so that the root surface is flat and smooth. Gingival connective tissue may reattach to the root surface and form a new attachment, which is called root surface flattening. After thorough scaling and root leveling, the inflammation and swelling of the gums subsided, bleeding and purulent discharge stopped, and the periodontal pocket became shallow and tight. The former is due to gingival recession and regeneration of collagen fibers in the connective tissue of the bag wall, which makes the gingiva dense and the probe no longer goes deep into the connective tissue. There may also be new connective tissue attached to the root surface. The compactness of the bag is due to tissue densification or scar repair on the inner wall of the bag. Scaling and root planing are the basic treatment methods of periodontal disease, and any other treatment methods should only be used as a supplementary means of basic treatment.
(3) Periodontal surgery: After the above treatment, if there is still a deep periodontal pocket, or the root calculus is not easy to be completely removed and the inflammation cannot be controlled, periodontal surgery can be performed. Its advantages are that dental calculus and unhealthy granulation tissue on the root surface can be completely scraped off under direct vision, and the shape of alveolar bone can be trimmed if necessary, or the affected root can be removed to correct the shape of soft tissue.
(4) Fixation of loose teeth: The periodontal splint made of metal wire ligation, composite resin or self-setting plastic reinforcement can connect a group of teeth with their adjacent stable teeth, so that the force can be dispersed on a group of teeth, and the periodontal tissue function reserve force of the group of teeth can be exerted to reduce the damage to individual teeth caused by super gravity or lateral torsion. This fixation is beneficial to the repair of periodontal tissue. After general periodontal fixation, the teeth are stable and the chewing function is improved. In some cases, after several months of treatment, X-ray can show the effects of neat alveolar bone margin and dense bone. However, it must be considered that the removal of plaque should not be hindered when making splint. If the patient has missing teeth and abutment or adjacent teeth need to be fixed because of looseness, a certain fixing device can also be designed on the removable denture, or a well-made fixing bridge can be used to fix the loose teeth.
(5) Unplug the teeth that can't be saved as soon as possible, so as to facilitate the treatment and tissue repair of adjacent teeth and avoid unilateral chewing caused by teeth.
(6) Clinically, the relationship between moderate and severe adult periodontitis patients should be carefully examined, and X-ray films should be consulted. If obvious interference and trauma are found, tooth adjustment and tooth loosening should be carried out after plaque control and inflammation elimination to establish a more balanced relationship. Clinical research shows that careful and correct adjustment can improve the effect of basic treatment, further stabilize teeth, improve chewing efficiency and improve the physiological function of mandibular movement and masticatory muscles.
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17.2 Systematic treatment of simple periodontitis is generally a chronic process. Antibiotics are generally not used unless acute symptoms appear. In severe cases, oral metronidazole 0.2g, 3-4 times a day, * * * 1 week, or spiramycin 0.2g, 4 times a day, * * * 5-7 days. Some patients have chronic systemic diseases, such as diabetes, anemia and digestive tract diseases. These systemic diseases may interact with periodontitis and accelerate the progress of periodontal damage, so it is necessary to control systemic diseases at the same time.
18 prognosis Most adult periodontitis patients are under control after proper treatment. But there are also a few patients with poor curative effect. Hirschfeld et al. (1978) reported that 600 patients with periodontitis were followed up for an average of 22 years. After that, 83% of the patients had a good curative effect, 13% of the patients got worse (4-9 teeth were extracted per person), and 4% of the patients got worse (10-23 teeth were extracted per person). The latter two types of patients are called refractory periodontitis. At present, a lot of research is being done on this kind of patients. There are a large number of Bacteroides gingivalis, Bacteroides Forsythia, Actinobacillus actinomycetemcomitans, Wolliana rectum, Fusobacterium nucleatum and so on in its subgingival plaque. Page thinks that the causes of refractory periodontitis may be: ① special pathogenic bacteria; (2) the body's defense ability is reduced; (3) The morphology of teeth and periodontal diseases hinders the complete elimination of pathogens.
19 prevention of adult periodontitis actively treat basic oral diseases and maintain oral hygiene.
Collagen, metronidazole, spiramycin.
2 1 salivary mucin correlation test
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